Hunter & Central Coast ICTN

Transcription

1 Hunter & Central Coast ICTN Scoping novel rural mental health clinical placements for undergraduate nursing and social work students in Northern NSW Final Report: 20th November 2015 University of Newcastle Department of Rural Health in partnership with the University of Newcastle, University of New England and Hunter New England and Central Coast Primary Health Network Ms Fiona Little Professor Tony O Brien Professor Mel Gray Dr Rhonda Wilson Ms Amanda Finn

2 Funding Period: July 2015 November 2015

3 Table of Contents 1. Introduction Background Project Objectives Methodology Consent and ethics Phase one scoping activities Phase two scoping activities Services directory and organisation eligibility Participant recruitment Results Phase one results Mental health curriculum summary... 6 (i) Nursing... 7 (ii) Social Work Rural mental health placement summary- Nursing... 8 (i) University of Newcastle... 8 (ii) University of New England Rural mental health placement summary- Social Work (i) University of Newcastle (ii) University of New England Rural mental health placement student evaluations Phase two results Organisation description Placement capacity of new organisations Barriers to placement Organisation support for placement i

4 5.2.5 Re-contextualising student learning in rural community-based mental health placements (i) What might be the components of the students learning requirements? (ii) Who might the students learn from? (iii) How might the learning be different in the context of rural mental health practice? Key findings Limitations Recommendations Appendix References ii

5 List of Tables Table 1: University of Newcastle- Nursing undergraduate rural placement Table 2: University of Newcastle-Nursing undergraduate rural placement Table 3: University of New England- Nursing undergraduate rural placement Table 4: University of New England-Nursing undergraduate rural placement Table 5: University of Newcastle 2014-Social work undergraduate rural placement Table 6: University of New England-Social work undergraduate rural placement Table 7: University of New England- Social work undergraduate rural placement Table 8- Organisations scoped i

6 1. Introduction The project Scoping novel rural mental health clinical placements for undergraduate nursing and social work students in Northern NSW commenced in July 2015 through the support of grant funding provided by the Hunter and Coast Interdisciplinary Clinical Training Network (HCICTN). The project aimed to investigate rural mental health placements for nursing and social work students in Northern NSW with scoping conducted for the development of potential new mental health placement providers located in the rural community setting. The research was conducted from the auspices of the University of Newcastle s Department of Rural Health in Tamworth, with the research team comprising academics from UNE and UON. The study was completed in November 2015 with final recommendations defined to shape the future development of community-based rural mental health placements. 2. Background In Australia, it is known 13% of the population is living with mental illness with more than 80% of people diagnosed with mental health problems falling into the spectrum of mild to moderate disorders (Australian Institute of Health and Welfare.2011). The 2014 Report of the National Review of Mental Health Programmes and Services identified however that mental health resources including the mental health workforce were higher in the acute spectrum of public healthcare, with the system failing to focus adequate attention on lower prevalence diagnosed mental health disorders within the community. To reduce the increasing impact from mental illness within Australia, particularly in rural and remote areas where there is less availability of a specialised mental health workforce, strategies are required to enhance detection, prevention and care for people living with mental illness. Access to a well-trained mental health workforce that has the capability to deliver care within upstream services is one solution to achieve this with new health graduates being adequately provided the skills to intervene appropriately (Wynaden 2010). It is therefore important that universities contribute to the health workforce and ensure graduates have meaningful clinical experiences and develop positive attitudes towards the healthcare of people living with mental illness. This also presents a challenge for universities attempting to acquire sufficient rural and regional mental health placements as placement opportunities such as this are limited. 1

7 Universities and leading mental health nursing academics have been concerned about the quality and quantity of mental health clinical placements throughout Australia for some time (Moxham, McCann, Usher, Farrell, & Crookes, 2011). In 2008, the Mental Health Nurse Education Taskforce was established to examine this issue and to reinforce the importance of nursing curricula to include mental health nursing, including clinical placement in mental health settings as a national priority (Mental Health Nurse Education Taskforce (MHNET, 2008). Traditionally, most clinical education for health professional students has taken place in the teaching hospital, in partnership with the relevant disciplines in the University. Increasingly educators have questioned whether this style of clinical education gives students the breadth of clinical experience needed for provision of appropriate health care for all people in the community. Moving more of the curriculum into the community, where patients reside, and using the range of community services delivering patient care, is likely to broaden student clinical exposure (Thistlethwaite, Kidd, & Hudson, 2007).Rather than involvement in short episodes of inpatient mental health care, in the community students can be involved in health promotion and prevention, and chronic disease management while on placement in a communitybased organisations. In providing mental health care it is important to develop professionals with the attributes to promote and maintain community mental wellbeing, and cost-effectively prevent and/or manage the increasing problems associated to mental ill health. Expanding the mental health professional education into the community should also include increasing clinical placement capacity. Clinical placements in rural and regional mental health settings are difficult to achieve for a range of reasons. First, there are fewer mental health services in rural and regional settings compared to metropolitan locations. Fewer mental health services result in fewer clinicians who are available to supervise clinical placements. Course accreditation requirements further limit the number of clinicians who are able to supervise students. For example, the Australian Nursing and Midwifery Accreditation Council (ANMAC) has stipulated that pre-registration nursing courses require that nursing students must be directly supervised by a registered nurse while in the clinical setting and this is linked to the scope of practice and competencies of both the student and the supervising registered nurse (Nursing and Midwifery Board of Australia, 2006). 2

8 In addition, many services in the study region are delivered via drive-in-drive-out (DIDO), fly-in-fly-out (FIFO), or using e-health and/or tele-health technologies with this mode set to increase in the future (New South Wales Health, 2012). This mode of delivery is usually fractional in nature, and thus limits the opportunity for students to work with a clinician to complete sufficient hours of clinical placement in the locations where these types of mental health services are delivered (Haslam McKenzie, 2013). Metropolitan-based telephone triage for mental health conditions contributes to another limitation for clinical placement experience in rural and regional centres, with a first contact to enter public mental health services accessed via this intake method (New South Wales Health, 2012) despite the relative dissatisfaction with these types of triage service by consumers (Elsom, Sands, Roper, Hoppner, & Gerdtz, 2013). However, the literature suggests ways to improve the quality and quantity of regional and rural placements. In the case of nursing students, these include suggestions on how to prepare students for, and supplement, placement experiences. Examples are the recommendations that students undertake Mental Health First Aid (Jorm, Kitchener, Fischer, & Cvetkovski, 2010) as a prerequisite to their course (Happell, Wilson, & McNamara, 2014); that Universities supplement face-to-face clinical placement with simulated clinical experiences within the context of mental health nursing units or courses (Wilson & Hungerford, 2015); or that Universities and health providers collaborate to support clinical preceptorship mentoring and supervision using innovative digital technologies, such as shared platform virtual learning environments to enhance learning, teaching, and reflection (Paliadelis et al., 2014). As regards social work, Renouf and Brand (2005) reported on Australian Association of Social Workers (AASW) data on social work education on mental health across schools of social work in Australia. The study found that: (ii) teaching of mental health knowledge and skills for social work is variable across the schools, ranging from solid to very limited; (ii) teaching and research in mental health within the schools appeared to depend heavily on the presence of qualified and interested staff; (iii) smaller schools offering generic programs, with no capacity for elective study in mental health, faced added problems in teaching specific mental health skills and knowledge; and schools of social work had to that point, been untouched by the concepts underpinning the education and training initiatives of the National Mental Health Strategy. The study gave rise to subsequent competency standards for social work practice in mental health being developed as well as minimal requirements for mental health to form part of the social work curriculum. 3

9 Renouf and Brand (2005) also highlighted some key practice issues for social work in mental health including: (i) the need to establish a viable paradigm for practice; (ii) a more positive response to the challenge of evidence-based practice models; (iii) a national agenda for education and training; and (iv) the importance of working collaboratively with consumers and families in a way that valued their human rights and the lived experience of mental illness (p. 419). This highlights social work s key focus on service-user interests and rights and critical focus on the impact of changes in the mental health system, where community caseworker positions tend to be filled by health professionals drawn from a broad range of disciplines, most commonly from nursing, psychology, social work, and occupational therapy, as well as Aboriginal mental health workers (Health Workforce Australia, 2013, in Cosgrave et al., 2015, p. 3). Renouf and Bland (2005) note that social work has been an active player in major workforce projects addressing the need for competent health professionals and recognises the importance of field placements in social work education, and the unique character of social work in rural mental health settings. By placing students in rural community-based services there is significant potential for both undergraduate nursing and social work students to benefit from learning in a way that provides a different focus through a different setting and rural geographical location, with the learning of clinical knowledge and skills closely linked to the needs of local health services and populations. To address the shortage and maldistribution of the mental health workforce, it is necessary to scope the capacity for expanded and new mental health educational settings. 3. Project Objectives This project aimed to scope new mental health clinical placements within rural community-based organisations for undergraduate nursing and social work students. The scoping occurred over four sites in Northern NSW within the jurisdiction of the University of Newcastle Department of Rural Health (UONDRH), and the School of Health, University of New England. There were two phases to this scoping project: Phase 1 examined student and curriculum data and Phase 2 explored the perspectives of community-based rural organisations. The project intended to: 1. Map the quantity and quality of current rural mental health placements, particularly with attention to location and setting. 4

10 2. Evaluate past clinical placements to determine evidence of student satisfaction and potentially assist in the planning processes for new placements. 3. Discuss with universities education providers to determine the number of nursing and social work students accessing rural mental health placements and to outline the structure of the mental health curriculum for both disciplines. 4. Scope rural community-based organisations that provide services to people experiencing symptoms of mental ill health as potential placements. The aim of this scoping was to explore different organisational views as to their capacity to provide placements. Qualitative data was gathered to assist in defining the requirements for student learning in these new settings. 4. Methodology 4.1 Consent and ethics Ethics approval was obtained through the University of Newcastle Human Research Ethics Committee. Scoping tools for the qualitative aspects of the study were developed for inclusion in this application including the (i) Interview Questions and (ii) Focus Group questions (see Appendix i and ii). Approval was granted for all aspects of the projects scoping activities to proceed (H ). 4.2 Phase one scoping activities In order to map the quantity and quality of mental health placements data was sourced from relevant databases including ClincConnect, StarRez, and Nustar. ClincConnect is an internet based tool that assists NSW health facilities and universities to coordinate and manage clinical placements. NuStar is the UON database for student enrolment and records, while StarRez is the student placement and accommodation database for the UONDRH. Student placement evaluation reports were also extracted from the UONDRH survey database. Data was obtained for mental health placements that occurred during 2014 and 2015 to provide a comparison of student numbers and placement location. Data relating to specific aspects of the curriculum for nursing and social work students was also obtained through liaison with UON and UNE academic staff, university Clinical Coordination Units and field education officers. 5

11 4.3 Phase two scoping activities Services directory and organisation eligibility To effectively include all eligible agencies suitable for the review within the criteria of the project, an Organisation Services Directory was developed. Service information was gathered and informed by the research team s collective personal knowledge of clinical services in the region, and further searches were undertaken to locate and include information from regional council community directories, existing community mental health services directories, recommendations from other organisations and relevant internet directories. Organisation eligibility for inclusion was determined by selecting community-based organisations that (a) provided direct mental health interventions with their primary focus as working with people referred specifically with a mental health problem; or (b) organisations that who did not identify exclusively as a mental health organisation, but who assisted a high percentage of their clients with coexisting mental health concerns as a regular provision in their usual service delivery Participant recruitment Participants were recruited initially by phone contact, and then later contact was by . Information sheets about the project were provided to eligible participants and informed consent was gained prior to the commencement of interviews. Participants were invited to contribute their views either through either an individual semistructured interview, or by attending a scheduled focus group. All interviews were audio recorded. 5. Results 5.1 Phase one results Mental health curriculum summary Liaison with university Clinical Coordination Units, field education officers, and academic staff occurred across two disciplines at the UON and UNE. It was revealed that nursing and social work placement course structures are in many ways similar based on their national standards and guidelines, however there was some differences around the timing of mental health content and placement in the curriculum, the number of compulsory units and the coordination of placements. 6

12 (i) Nursing The UON Bachelor of Nursing (BN) degree requires students to complete 800 hours of clinical experience in accordance with ANMAC requirements. Clinical experiences are usually divided across semesters in relation to the clinical unit, year of enrolment and semester of the degree program. The core units for professional practice in mental health nursing occur as a two week placement (80 hours) in the second (compulsory/core) and third year (Elective) of the degree (units are offered in both semesters), as either a mental health or aged care setting. During scoping it was identified that these placements generally occur in public health facilities and community-based opportunities were very limited. The UON BN in 2015 has approximately 1931 students enrolled across the BN program and three campuses; in second year where the mental health core course resides across campuses there are approximately 500 students. The UNE pre-registration courses Bachelor of Nursing and Master of Nursing Practice, requires that students complete 880 hours of clinical practice in total. This is undertaken in a variety of health service settings across all trimesters, however most of the placement load falls within trimesters one and two each year. Clinical practice is normally organised in block placements of two to four weeks throughout the six trimesters of the course. Students must successfully complete a compulsory mental health practice placement in a mental health setting for 80 hours in the second year of their program. There was a total of 226 students who attended clinical placement in The total number of students placed in a rural location was 52. Coordination of mental health placements for nursing students at both universities is arranged through ClinConnect with significant barriers identified that are specific to providing a rural mental health placement. Insufficient numbers of placement sites and appropriately qualified on-site supervisors were identified as being the most challenging to overcome. (ii) Social Work The UON undergraduate social work degree requires students to complete two student placements of 490 hours each which occur in the third and fourth year of the Bachelor of Social Work degree, in keeping with the Australian Association of Social Workers (AASW) education standards. UON does not have a designated compulsory mental health placement, however outlines that students learning of mental health issues occurs across many placement opportunities due to the high prevalence of people living with mental illness in the community. The UON uses 7

13 inpatient and community mental health placements; it was reported in participant interviews that they predominantly use the acute mental health services. The UNE requires all students to complete 1000 hours of field placement across two separate field placement units, one in the third year of 450 hours and the second of 550 hours in the fourth year. UNE outline that approximately five percent of their social work students attended a rural mental health placement. With regard to social work at the UON, there is no requirement for students to undertake a dedicated or compulsory mental health placement, as mental health issues exist in the context of most social work placements. A mental health placement is seen as one offered by an agency or organisation whose key business activity is mental health, such as inpatient and community mental health placements in NSW. Students do have the option of participating in a community-based placement that is not a NSW health facility and where mental health is the key focus of work (e.g. Richmond Fellowship). Barriers to accessing placement in rural areas relates to the availability of accommodation, student willingness to go rural and access to qualified supervisors Rural mental health placement summary- Nursing (i) University of Newcastle The 2015 UON placement locations occurred between two inpatient mental health units with relatively equal distribution of students across both sites. Public health community-based placements were offered to students across three key sites. There was a minimal increase in numbers (7 students) in Mental health placements occurred across both semesters with the larger percentage of placements occurring in semester 1. There were no placements at the Armidale site for 2015, as had been the case for 2014 (see table 1 and 2). 8

14 Table 1: University of Newcastle- Nursing undergraduate rural placement 2015 Location Facility Semester 1 UON Nursing student numbers Semester 2 UON Nursing student numbers Tamworth Banksia Mental Health Inpatient Unit 12 4 Community Mental Health 6 2 Taree Taree Mental Health Inpatient Unit 12 5 Community Mental Health 7 1 Forster Community Mental Health 4 Nil Total semester 41 students 12 students Total students placed across all sites: 53 Table 2: University of Newcastle-Nursing undergraduate rural placement 2014 Location Facility Semester 1 UON Nursing student numbers Semester 2 UON Nursing student numbers Tamworth Banksia Mental Health Inpatient Unit 5 5 Community Mental Health 1 2 Armidale Clarke Centre 3 5 Community Mental Health Team 0 2 Taree Taree Mental Health Inpatient Unit Community Mental Health 1 2 Total semester 20 students 26 students Total students placed across all sites : 46 (ii) University of New England Placements sites for UNE nursing students in 2015 were provided across nine individual rural sites with a significant proportion of placements occurring within the community setting (51%). Placements for 2014 showed that there were slightly less placement sites than 2015 with seven sites accepting student placements and slightly less overall ratio of students attending community health settings (45%). This percentage most likely occurs due to the UNE geographical location being situated in 9

15 the rural context and potentially having close connections and opportunity to access smaller rural based community mental health teams. Almost all placements for mental health occurred in the second half of the year during trimester 2 for both 2014 and 2015 (see table 3 and 4). Table 3: University of New England- Nursing undergraduate rural placement 2015 Location Facility Trimester 1 UNE Nursing student numbers Trimester 2 UNE Nursing student numbers Tamworth Banksia Mental Health Inpatient Unit 0 7 Community Mental Health 0 4 Armidale Clarke Centre 1 10 Community Mental Health 0 5 Glen Innes Community Mental Health 0 2 Gunnedah Community Mental Health 0 2 Inverell Community Mental Health 0 2 Moree Community Mental Health 0 4 Narrabri Community Mental Health 0 1 Forster Community Mental Health 0 1 Taree Taree Mental Health Inpatient Unit 0 5 Community Mental Health 0 3 Total semester 1 student 46 students Total students placed across all sites: 47 Table 4: University of New England-Nursing undergraduate rural placement 2014 Location Facility Trimester 1 UNE Nursing student numbers Trimester 2 UNE Nursing student numbers Tamworth Banksia Mental Health Inpatient Unit 2 4 Community Mental Health 1 2 Armidale Clarke Centre 1 3 Community Mental Health 0 4 Inverell Community Mental Health 0 3 Moree Community Mental Health 0 3 Narrabri Community Mental Health 0 2 Forster Community Mental Health 0 2 Taree Taree Mental Health Inpatient Unit 0 4 Total 10

16 semester 4 students 27 students Total students placed across all sites : Rural mental health placement summary- Social Work (i) University of Newcastle ClinConnect data relating to clinical placements occurring within public mental health facilities for social work students reflect one placement occurred in 2014 with no students identified attending a rural mental health placement in 2015 (see table 5). Table 5: University of Newcastle 2014-Social work undergraduate rural placement 2014 Location Facility Semester 1 UON Social Work student numbers Semester 1 UON Social Work student numbers Tamworth Banksia Mental Health Inpatient Unit 1 1 Total semester 1 student 1 student Total students placed across all sites: 2 (ii) University of New England Placements conducted between 2014 and 2015 showed six social work students competed a placement within the four selected rural sites. A majority of these placements occurred within 2015 (see tables 6 and 7). Table 6: University of New England-Social work undergraduate rural placement 2015 Location Facility Semester 1 UNE Social Work student numbers Semester 2 UNE Social Work student numbers Tamworth Banksia Mental Health Inpatient Unit 1 Community Mental Health (incl. 3 CAMHS) Armidale Community Mental Health 1 Total semester 2 students 3 students Total students placed across all sites: 5 11

17 Table 7: University of New England- Social work undergraduate rural placement 2014 Location Facility Semester 1 UNE Social Work student numbers Semester 2 UNE Social Work student numbers Inverell Community Mental Health 0 1 Total semester Nil 1 student Total students placed across all sites: Rural mental health placement student evaluations All health students attending a UONDRH placement are asked to complete a placement evaluation survey upon finishing their rural placement. Questions specific to the demographics of placement include; (i) satisfaction with orientation (ii) range and variety of learning experiences (iii) satisfaction with support provided by UONDRH (iv) satisfaction with workplace supervision (v) access to educational resources (vi) accommodation and (vii) intention to live rurally on graduation. Student evaluation data was extracted from the UONDRH student evaluation database for UON nursing students who had completed a rural mental health placement in A total of 25 students out of 53 completed a post placement evaluation (47% response rate). The demographic data for students who completed a survey is summarised as follows: 100% of students were female Age ranges were predominantly between years (13 students), with 6 students between years and 6 students were 39 years and over. Distribution of students between sites was relatively even with 14 students attending placement at Taree and 11 at Tamworth. 10 students reported never having lived in a rural location before however 10 students also reported having lived in a rural location for 10 years or more. The remaining 5 students reported spending between 1-9 years in a rural location. 10 students had previously undertaken a mental health placement 12

18 Qualitative data from the student UONDRH surveys was also examined where students were asked a series survey questions relating to a variety of aspects of their placement. Results from two questions were selected from the student surveys where they were asked what what they liked about their placements and what they felt could be improved. Students reported the aspects they enjoyed the most were increased opportunity to learn, exposure to working with mental health clients and experiencing work as part of a team. The negative aspects of placement overwhelmingly related to the lack of support from university staff and inadequate orientation to prepare for placement. The following quotes reflect the student s positive and negative views about their placement. What were the things you enjoyed most about your placement? The amount of opportunity that was provided at a rural hospital (more than an urban hospital such as John hunter). -Student 2 I loved the rural environment, the accommodation and hospital. Most of all I really loved the team I worked with on placement, they were really supportive and taught me so much. They really showed me what a good team is and it's the best I've seen so far. Best placement I ve had - Student 7 Experiencing a different side of nursing, finding it confronting yet extremely educational - Student 22 Experiencing what it was like in a mental health inpatient unit and being able to put aside my pre-conceptions about mental health. Meeting the nursing staff in the mental health inpatient unit and observing how well they work as a team - Student 14 Getting out in the community with mental health in community MH taught me more in 3 days than I learnt over the whole 2 weeks - Student 12 Because there was only a small number of students I was able to get more opportunities to put theoretical knowledge into practice and develop new skills - Student 21 13

19 Do you have any suggestions to improve these placements? I had no input from or any opportunity to debrief with the facilitator and I was not well prepared for the placement at all. For the first few days I was quite scared and unsettled due to the lack of prep and support. - Student 3 The organisation was quite poor. I didn't have a facilitator employed by the university and I spent a lot of time sitting around reading research because nothing had been planned for me to do. - Student 11 I experienced little interaction with my facilitator and was unable to contact my supervisor/ facilitator when I needed I also had my orientation 2 weeks after I had started my placement - Student 4 I was 'thrown onto' the ward with minimal introduction and time to adjust to the rural setting. - Student 18 I think orientation needs to run for a longer period of time and more education about the area/wards/aboriginal population/ facilities needs to be provided. - Student 17 It wasn't a good start to the placement for me as there was no clinical facilitator organised so I had no support the hospital didn't have anything to say I was coming so I didn't have an appropriate orientation and I felt like I was just put in the 'too hard' basket. I eventually sorted it out myself. -Student Phase two results The Organisation Service Directory was used as a framework to contact eligible community-based organisations across the four sites within the UONDRH jurisdiction. Contact was made to forty five organisations with seventeen in total consenting to participate. Of the interviews conducted nine were held in Tamworth, four at Moree and two interviews each held in both Taree and Armidale. Interview numbers were lower in Taree and Armidale due to cancellations of booked interviews and difficulty negotiating a time for the interview to be conducted within the time constraints of the project completion Organisation description The community organisations were divided into those that (i) provided direct mental health intervention and received referrals for clients with symptoms of mental ill health and (ii) those that were not identified as a mental health service but saw a high percentage of clients with associated mental health problems. 14

20 Table 8 demonstrates the type of organisations participating in the project, including the location and number of interview conducted. Table 8- Organisations scoped 1 Organisation Organisation name Location Interviews type Counselling Centacare, Anglicare, Life Connect Tamworth, 5 Counselling, Rural Financial Counselling Service. Armidale, Moree Aboriginal Pius X Medical Corporation, Maayu Moree, Taree 4 service Mali Alcohol and Other Drug Service, Byamee Homeless Service, Birripi Medical Corporation Primary health Smith St Practice (MHNIP), Tamworth 2 care service HealthWISE Youth service Headspace Tamworth 1 Rehabilitation Billabong Clubhouse, Richmond PRA Tamworth 2 and recovery Family service Family and Community Services Tamworth 1 Employment agency Private mental health facility** Peel Valley Training and Tamworth 1 Employment (PHaMHS Program) Mayo Private Hospital Taree Placement capacity of new organisations Previous student placements had occurred within eleven of the seventeen organisations interviewed. Placements for students completing university degrees were the most common including the Bachelor of Medicine, Bachelor of Nursing, Bachelor of Social Work, Bachelor of Psychology and Bachelor of Health Science (Mental Health). TAFE students completing either their Diploma in Community Services or Certificate IV in Mental Health were also included as were students from the College of Counselling. 1 Although the Mayo Private Hospital is not regarded as a service within the community-based setting it was included in the directory because it provided a valuable private sector perspective to student learning. It addition the client-base attending this service are primarily higher prevalence mental health disorders with lower acuity. 15

21 Although the total numbers of students accessing these placements throughout the year were relatively small the infrastructure required to support students was well integrated into organisational policy and procedures. Orientation processes and access to learning resources were readily provided to students with a significant number of these organisations demonstrating a commitment to providing a learning environment that benefited the student, the organisation and most importantly the client Barriers to placement Organisations identified a number of potential barriers to students accessing their service as a rural mental health placement site. Some of these included concerns about having enough staff with appropriate qualifications to supervise students having adequate workforce resources to allow time to be allocated to students without impacting on the functioning of the service and sufficient clinical work to make clinical placement a valuable learning opportunity for students Organisation support for placement A variety of options was provided by the organisations interviewed with regard to how additional support might be provided to enable student placements occur. The majority felt additional training in provision of supervision to students would be beneficial along with clear expectations around student learning objectives. A participant explained: The biggest thing would be having a clear objective (about learning) so then we know what we have to prepare for to support them support and exposure to a variety of different things making sure there are clear expectations that can be met. Two organisations interviewed had already completed field education supervision training but a majority of organisations had formal strategies in place to ensure the students they had supervised were provided with a positive learning experience Re-contextualising student learning in rural community-based mental health placements The community-based organisations interviewed proposed a different experience to students through (i) the components of their learning requirements, (ii) who might they learn from and (iii) how caring for people living with mental ill health differs in the context of the rural community-based setting. These questions arose as a summary 16

22 from the questions asked in the semi-structured interviews and were shaped from the responses provided by the organisations interviewed. A majority of the organisations interviewed offered broad exposure to the social and emotional pre-determinants to mental health through the work they conducted. The potential learning outcomes therefore focused on the development of a broader view about mental health care as seen through the function of these organisations. The value of student placement was well recognised by all organisations interviewed as an important element to student learning as was its role in contributing to readiness for professional practice. The predominant view was that communitybased placements that focused on different aspects of learning about mental health could augment the learning already provided within the public health setting. (i) What might be the components of the students learning requirements? Of all the people living with mental illness there is an increasing prevalence of mental illness occurring within the mild to moderate spectrum for people living in rural communities. Students placed within community-based organisations that see a higher proportion of this population provides greater exposure to the development of skills in early intervention and prevention. These skills potentially assist the student to understand the decision making processes that occur at the early stages of assessment and treatment while still caring for that person outside the hospital setting. Broader learning, diversity and preparation for practice The community organisations interviewed valued the merit of understanding the welfare aspects associated to mental health care and the contribution to the development of these skills: Learning experiences need to be broad getting an understanding of family and community (Organisation 7). It makes for a more skilled worker they re seeing that cause and effect stuff before they (the person) gets to that acute stage of going to hospital (Organisation 14). Exposure to a variety of work programs and settings offered by community base organisations provides another kind of introduction to clinical scenarios that vary to those in the hospital setting: 17

23 Having students involved in all the programs would be great because there they d get a very wide range of experiences under our drought program we go out to people on their properties and that is very different to what it s like when you re in a room with them (Organisation 4). Organisations also valued the importance of student placements that reflected the authenticity of what the placement had to offer in its contribution to workplace readiness: I think if you are going to be doing placements in mental health then you want to get the true gist of what s going on out there I struggle with placements if the participant doesn t get a real feel for what is going on in the real work life (Organisation 9). Contribution to holistic care It was widely regarded that students would benefit from spending time within organisations that received referrals for people with a lower level of mental health acuity. Exposure to this end of the spectrum of care potentially contributed overall to the student s mental health literacy and ability to deal with comorbidity between mental and physical health: Taking that taste of mental health into whatever area they re going to I don t expect all (students) to be mental health nurses but to be aware of it to make that referral I see aged care and mental health nursing to be the last vestiges of holistic care (Organisation15). The emphasis on students being able to learn about all aspects of mental health care and to take a broader social view was acknowledged. There was the recognition that working in rural mental health care requires the application of these views in a way that incorporates all elements of health and requires a diverse approach in the delivery of the care required: If you (the student) come out of that sort of training and you have a better understanding of that big wide world out there of community welfare sector in a sense, it encompasses health and everything in a way rather than the narrow focus. You re got to be better off as a worker with that knowledge and your network before you get out (Organisation 13). As a rural mental health practitioner you need to have a huge range of skills you can call on you have to have a really holistic approach (Organisation 2). 18

24 Informal learning In alignment with the approach to offering students broad learning experiences, many organisations placed high value on the tacit aspects of learning that occurred in the context of practice within community-based rural health organisations: One of the most important things they could learn is that there should be no such thing as silos. It should be mandatory in some way teach (students) how to collaborate, how to integrate services, how to make it (a service) as seamless as possible for people to see the values and strengths of each organisation and how you make them work (Organisation 13). It was felt that students would benefit from having a bigger picture view of how organisations function in rural areas where resources are scarce and to understand the need to develop skills that will enhance their clinical practice: Students could learn about systems and processes in rural areas where services are lacking (Organisation 6). The community support staff, they ve gotta know Centrelink process inside and out and there s no qualification that teaches you that the life skills all that advocacy and support and knowing that system and to streamline it, making them aware that this is a process (Organisation 14). Specific skills With regard to specific learning to targeted populations there was an overwhelming response that cultural learning needed to occur prior to students undertaking any placement in a rural area: One of the main advantages for the benefit of the wider community is if they (the student) gets to understand Aboriginal people and those complexities that they will help people interact with Aboriginal people better (Organisation 14). (ii) Who might the students learn from? It is well evidenced in the literature that people living in rural areas face greater difficulties in accessing mental health care and have specific social and environmental causes that contribute to their mental health issues (Inder, Berry &. Kelly 2011; Kelly, Lewin, Stain, Coleman, Fitzgerald et.al. 2011).People experiencing distress associated with these factors receive support through organisations that deal 19

25 with welfare issues such homelessness, domestic violence, and drug and alcohol use. Students accessing placement in these organisations are therefore likely to receive higher exposure to undifferentiated mental health presentations. Although it is likely for students to receive similar learning experience in a metropolitan communitybased setting, the view among the organisations interviewed was that the impact was more significant in rural areas: In a rural area most clients are facing more hurdles such as unemployment, access and time to get into drugs and alcohol the hurdles are higher I don t think they are any different (to metro) but they are higher (Organisation 1) Populations at greater risk Populations that organisation felt were consistently at higher risk for mental ill health in rural areas were Aboriginal people and farming families. Both experience social stressors that contributes to their mental wellbeing and as a result the approach to providing intervention needed to take these factors into consideration. For students on placement in community organisations working with Aboriginal people or farmers it was regarded beneficial to have an understanding of these dynamics including the skill set and approach required to engage with both populations. It was widely thought that social stigma was a significant barrier to accessing help and that the development of rapport, engagement and appropriate communication skills was essential to facilitate connection with these hard-to-reach groups: People here described working with the farming community is like working with the indigenous community there s a sort of difficulty breaking in for a range of reasons. They might not be exactly the same but you run into similar difficulties in terms of engaging being accepted into the community so you can offer support. (Organisation 13). Organisations were asked their view about the specific underlying determinants that placed Aboriginal people and farmers at risk of poorer mental health, and what they felt students needed to learn. For farmers the uncertainly associated with dealing with fluctuating changes of nature, their reliance on climatic conditions and the economic impact of these factors is an important aspect of student learning, as well as the deeper dynamics and emotional impacts of these factors on the farming way of life: 20

26 The outer influences on life here are so very different there are a lot of external shifts that impact on the internal work of rural people that they don t often understand themselves very different things are important for them, the climatic changes and influences in their livelihood is huge (Organisation 17). The dynamics of a family on a farm farming it s difficult to separate business and family (Organisation 16) I think if you are born and grow up on a farm you have dirt in your bones (Organisation 13) For some Aboriginal people some of the issues were reported to be about identity and belonging; the absence of a sense of social connection impacted heavily upon mental wellbeing: For Aboriginal people it s about connectedness, people who come through here they re lost themselves it s the disconnectedness of who you are and the impact of this on mental ill health and substance abuse (Organisation 9). Understanding culture The need for students to understand Aboriginal culture on a much stronger level was emphasised by many rural community organisations with students being given the opportunity to learn about and understand the cultural past and associated trauma of the rural area in which they are doing their placement: The biggest thing is...i don t think to (just) be empathetic.you (the student) needs to learn to listen listen a bit deeper than what you normally would listen from the point of view of understanding where that persons at, understanding some of that historical aspects and understanding in a deeper way (Organisation 9). Commitment to rural work The professionals themselves who worked within the organisations felt their reasons for remaining committed and dedicated to rural practice were worth incorporating into students learning as part of the rationale for a student to consider working in rural practice: I would hope through my passion though my work. this would encourage them (students) to get a love for this kind of life (Organisation 6). 21

27 This town as hard as things have been for some people it s the drive that keeps us going every day. A lot of us who are in this game don t do it for ourselves we do it for the bigger picture which is for our community and we have a sense of pride about our town (Organisation 9). Community engagement The emphasis on including some of the students learning with aspects of the community were also considered potential incentives for influencing recruitment to rural areas. It was considered that a student placement should not exist in isolation to developing their understanding of the community in which the placement was occurring and the dynamics of community engagement: If we can show them (students) some good events with the community and have that successful engagement, that positive engagement the students may form attachments (to the way of life) (Organisation 14). I think a student through their experience whether coming into this setting, whether it s going into a hospital setting, going into a community setting if you re going to come out and work in these environments then go and immerse yourself into these communities (Organisation 9). (iii) How might the learning be different in the context of rural mental health practice? Mental health practice in rural areas comes with its own set of challenges. Limited access to specialised services and qualified health professionals pose difficulties in integrating care with all too frequent gaps emerging in the intervention process. The complex and diverse nature of mental illness in rural practice, combined with limited resources, often means that greater levels of collaboration are required to provide care. In addition, through the process of collaboration organisations are able to share the responsibility and find the necessary support to meet the needs of their clients. The organisations interviewed felt that students observing the processes of collaboration and interprofessional practice while on placement, would enhance their awareness of how these integrate with mental health care provision in rural locations. It was strongly viewed by all organisations that rural practice was different to that in metropolitan locations and, as a result, the way people worked was also different. Participants suggested: 22

28 Huge, massive. I used to work in the Hunter and even the difference to here but then if you compare it to Sydney it s a different world again and we re not even as rural as you can get (Organisation 12). The variety in presentations is greater in a rural area. In metro areas you have a lot more specialised services when we talk to our city counterparts they don t understand there aren t 3 or 4 or 5 different counsellors that we can go to. You are very limited in professionals in any field (Organisation 8). Organisational collaboration The connection to people in other organisations and the strength of these relationships was highly valued by community-based organisations. As the intervention phase might begin when a person first links with an organisation, the decision-making processes are often required to involve a number of organisations to keep a person well within that community: Relationships with the other services is vital, absolutely vital the benefits of the clients are potentially compromised if workers don t get along (Organisation 8). Working out here you need to be flexible enough to change to get the job done Relationships with other organisations is massively important. I need to make sure the links between services are meaningful if you don t work collaboratively you don t survive rurally (Organisation 9). 6. Key findings There are distinct discipline differences in the way nursing and social work undergraduate courses coordinate and conduct mental health placements in general. The community-based organisations interviewed demonstrated viable merit as potential learning environments for both undergraduate nursing and social work students. From the evaluations students were generally positive about the learning experience obtained from their mental health placement, however students expressed a lack of structural support around these placements. Community-based organisations have potential to provide students with broader learning opportunities that capture a greater overall perspective of the spectrum of mental health care provision. 23